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Prostate cancer tests are now OK with panel, with caveats

CHICAGO — An influential U.S. government health panel is dropping its opposition to routine prostate cancer screening in favour of letting men decide for themselves after talking with their doctor.

The new draft guidelines echo those of several leading medical groups, but they don’t make the decision any easier for men: With their doctor’s help, they have to decide whether to take an imperfect PSA test that has a small chance of detecting a deadly cancer and a larger chance of triggering unneeded worry and treatment with serious side effects.

“This isn’t a one-size-fits-all” recommendation, said the panel’s chair Dr. Kirsten Bibbins-Domingo, a San Francisco internist who already follows the advice and discusses the potential pros and cons with her patients.

Men whose greatest concern is reducing their chances of dying from cancer are sometimes willing to face the consequences and choose testing. “Other men will realize the likely benefit is small and aren’t willing to risk the harms,” she said.

PSA screening to detect the most common male cancer is among the most heated topics in men’s health. It involves a simple blood test for elevated levels of a protein that may signal cancer but also can be caused by less serious prostate problems. It can find cancer that frequently doesn’t need treatment because it’s too small and slow growing to become deadly. Doctors say there’s no good way to tell which early cancers might become lethal. The next step is often radiation or surgery to remove the prostate, which may result in impotence and incontinence.

The U.S. Preventive Services Task Force says its latest recommendation is based on new evidence indicating that routine PSA blood tests can slightly reduce some men’s chances of dying from prostate cancer and that drastic treatment can be avoided with close monitoring when cancer is detected.

The shift shelves the panel’s 2012 guidance, which prompted criticism from some urologists ‚Äî specialists who treat the disease ‚Äî and angered some prostate cancer patients certain that PSA screening had saved their lives.

The new advice published Tuesday closely aligns the panel with medical groups that also support shared-decision-making. The biggest remaining difference is timing. The task force draft says screening conversations should begin at age 55. Other groups say start earlier, depending on family history of prostate cancer and other factors. It recommends against testing men aged 70 and older.

The panel leaves open how often men should be screened. It does not recommend earlier testing for blacks and those with a family history but says they should know their risks are higher.

Dr. Meir Stampfer, a Harvard University cancer expert, called the new advice “a more reasoned approach.” He said PSA tests make sense if they do not lead to overly aggressive treatment. His research suggests that more than 1 in 5 men worldwide have undetected prostate cancer, including more than 40 million Americans, but that most will die of other causes.

The task force’s 2012 advice against screening said there was little evidence that PSA screening was reducing deaths. Since then, PSA screening rates have declined by as much as 10 per cent, and now fewer than one-third of U.S. men get the tests. Fewer men are being diagnosed with early-stage disease, when it is more treatable, while more are being diagnosed with more aggressive harder-to-treat cancer.

The panel says its new advice stems from long-term research indicating that for every 1,000 men offered PSA screening, one to two will avoid death from prostate cancer and three will avoid prostate cancer spreading to other organs.

Newer research also has shown benefits from “active surveillance” of men whose initial PSA tests and biopsies indicate slow-growing cancer that hasn’t spread, the panel said. This approach includes repeated PSA tests and close monitoring, which can delay or even avoid the need for treatment.

The task force’s recommendations influence U.S. government policy and are widely followed by primary care physicians. Medicare and many private insurers have continued to pay for the screening. The government-appointed volunteer panel reviews evidence and issues advice for a variety of screenings and treatments.

“It sounds like cooler heads have prevailed,” said Dr. Jim Hu, a urologist and prostate cancer specialist at New York-Presbyterian/Weill Cornell Medical Center who called the old advice “draconian.”

The prostate cancer recommendations, announced online in the Journal of the American Medical Association, are open for public comment on the task force website until May 8. Final guidance will come months later but the panel’s guidelines typically echo its draft advice.